The charge nurse observes a nurse performing interventions for a client who has just arrived in the post-anesthesia care unit following right cataract removal and intraocular lens implantation. Which intervention would require the charge nurse to intervene?
The nurse waits 5 minutes between administering prescribed eye drops.
The nurse leaves the eye shield in place while the client sleeps.
The nurse is instructing the client not to drive at night.
The nurse encourages the client to exercise with 20 lb weights 1 day post-operatively.
The Correct Answer is D
Choice A reason: The nurse waiting 5 minutes between administering prescribed eye drops is a standard practice to allow each drop to be properly absorbed and avoid dilution of the medication. This intervention does not require any action from the charge nurse.
Choice B reason: Leaving the eye shield in place while the client sleeps helps protect the eye from potential injury or infection after surgery. This is a recommended practice and does not need intervention from the charge nurse.
Choice C reason: Instructing the client not to drive at night is a reasonable precautionary measure given the client's recent eye surgery and potential vision changes. This instruction does not warrant intervention from the charge nurse.
Choice D reason: Encouraging the client to exercise with 20 lb weights one day post-operatively is inappropriate and requires the charge nurse to intervene. Strenuous activity can increase intraocular pressure and compromise the healing process after cataract surgery. The client should avoid heavy lifting and follow the post-operative care instructions provided by the healthcare team.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Pyridostigmine is a medication used to treat myasthenia gravis by inhibiting acetylcholinesterase, but it is not used as an antidote for edrophonium overdose. Pyridostigmine helps improve muscle strength by increasing the amount of acetylcholine available at the neuromuscular junction.
Choice B reason: Flumazenil is an antidote for benzodiazepine overdose and has no effect on edrophonium. It works by competitively inhibiting the actions of benzodiazepines on the GABA receptor.
Choice C reason: Acetylcholine itself is not used as an antidote for edrophonium overdose. Administering acetylcholine would not counteract the effects of excessive acetylcholinesterase inhibition caused by edrophonium.
Choice D reason: Atropine is the correct antidote for edrophonium overdose. Atropine is an anticholinergic drug that can counteract the excessive accumulation of acetylcholine caused by edrophonium, thereby alleviating symptoms such as bradycardia and muscle weakness.
Correct Answer is D
Explanation
Choice A reason: Bright light sensitivity is a common side effect following cataract surgery and can be managed with appropriate measures such as wearing sunglasses. It does not necessarily indicate a complication requiring immediate reporting.
Choice B reason: Difficulty seeing with a patch on one eye and fear of falling are valid concerns, but they do not necessarily indicate an immediate complication that requires urgent reporting to the healthcare provider.
Choice C reason: Eye itching is common after cataract surgery, and the client should be advised not to rub the eye to prevent infection or damage. This comment does not indicate a severe complication that needs immediate reporting.
Choice D reason: Severe eye pain that the client cannot stand is a potential sign of a serious complication, such as increased intraocular pressure, infection, or other postoperative issues. This requires immediate attention from the healthcare provider to prevent further complications and ensure the client's safety.
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